Healthcare Provider Details

I. General information

NPI: 1851779680
Provider Name (Legal Business Name): PHILLIP MYTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 EXECUTIVE CT STE 302
LITTLE ROCK AR
72205-4551
US

IV. Provider business mailing address

204 EXECUTIVE CT STE 302
LITTLE ROCK AR
72205-4551
US

V. Phone/Fax

Practice location:
  • Phone: 501-744-4242
  • Fax:
Mailing address:
  • Phone: 501-744-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8052-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: